CDPH 286: California Pre-Kindergarten and School Immunization Record

Complete the pupil's identification section.

Enter the Pupil Name (Last, First, Middle), the Name of Parent/Guardian (Last, First), the Birthdate (Month/Day/Year) and the Gender.

The Statewide Student Identifier (SSID) is a 10-digit number assigned to TK/K-12 public school pupils by the California Department of Education.

For Ethnicity, the boxes are Hispanic/Latino and Non-Hispanic/Non-Latino. For Race, the boxes are African American/Black, American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander, White and Other.

Complete the vaccine and dose section using information from the pupil's immunization record provided by a parent or guardian, prior school, or an immunization registry.

Record the date (month/day/year) of each dose the pupil has received, even if the pupil has an exemption to one or more required vaccines. Any vaccine given four or fewer days prior to the minimum required age is valid.

Check the Permanent Medical Exemption (PME) box(es) for vaccines that are permanently exempt for medical reasons.

If all vaccines are exempted, then fill in the date for "Date Requirements Met" in the appropriate row in the Status of Requirements section.

File the medical exemption form specifying the exempted immunization(s) in the pupil's record.

Complete the appropriate row in the Status of Requirements section.

Review the pupil's immunization record for admission to pre-kindergarten (child care or preschool), transitional kindergarten/kindergarten through 12th grade (TK/K-12), or advancement to 7th grade.

Enter the initials of the staff reviewing the pupil's record.

If the pupil meets admission requirements, check the designated box (Has All Required Vaccine Doses) and enter the date under "Date Requirements Met." This date is usually the date records are determined to be complete.

For Follow-up Date(s), see the conditional admission schedule or the exemption end.

If the pupil does not have all required doses but is not due for any doses at the time of admission, check the "Missing Doses Not Currently Due-Conditional" box and fill in the "Follow-up Date(s)" space. For this box, review records at least every 30 days.

If the pupil has a Temporary Medical Exemption, check the designated box and write the expiration date in the "Follow-up Date(s)" space.

Once the pupil meets all admission requirements, fill in the date for "Date Requirements Met." This applies to the "Missing Doses Not Currently Due-Conditional" box and to a Temporary Medical Exemption.

If the pupil is due for doses and subject to exclusion, check the "Missing Doses Are Overdue-Needs Doses Now" box and fill in the "Follow-up Date(s)" space.

If the pupil does not have all required immunizations and does not meet criteria for conditional admission (including a temporary medical exemption) and is: IEP, accessing special education services required by the pupil's individualized education program; IND, enrolled in an independent study program and does not receive classroom-based instruction; or Home, enrolled in a home-based private school. Then, using the codes IEP, IND and Home listed here, check the appropriate box under "Other" and fill in the date for "Date Requirements Met."

Review the immunization information and supporting documentation for exemptions included in the pupil's record or other immunization record, verifying the pupil has met immunization requirements for the pupil's age/grade.

If the pupil has a Permanent Medical Exemption (PME), then add the pupil's name to your facility's roster of unimmunized pupils.

Provide this form or an equivalent immunization record as specified in 17 CCR section 6070(b) and any exemption documentation as part of the pupil's record.

California law requires schools to immediately enroll foster children transferring to their school even if the child is unable to produce immunization records normally required for school entry.

Within two business days of the foster child's request for enrollment, the educational liaison for the new school shall contact the school last attended to obtain all records.

The educational liaison for the school last attended shall provide all records to the new school within two business days of receiving the request (California Education Code section 48853.5(f)(8)(C)).

IPV / OPV (Polio): 4 doses meet TK/K-12 requirement, as do 3 doses, if ≥1 dose given at age ≥4 years. DTaP / DTP (Age 0-6 years) and Tdap / Td (Age 7+ years): 5 doses meet TK/K-12 requirement, as do 4 doses, if ≥1 dose given at age ≥4 years; 3 doses, if ≥1 Tdap dose at age ≥7 years. A Tdap dose may meet the 7th Grade requirement. MMR (Measles, Mumps, Rubella): 2 doses meet TK/K-12 requirement. Doses must be given at age ≥1 year. Hib (Haemophilus influenzae type b): Required for pre-kindergarten only. At least 1 dose must be given at age ≥1 year. Hep B (Hepatitis B): 3 doses meet TK/K-12 requirement. VAR / VZV (Varicella/Chickenpox): 2 doses meet TK/K-12 requirement. Tdap, 7th Grade (Tetanus, Diphtheria, Pertussis): 1 dose given at age ≥7 years meets requirement for 7th grade advancement and 7th-12th grade admission.